1.

Introduction to Mycology

Suzan Matar (PhD Medical Microbiology and Immunology)

Department of Clinical Laboratory Sciences

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Contents

General Properties and Classification of Fungi

Growth and Isolation of Fungi
Superficial Mycoses
Cutaneous Mycoses
Subcutaneous Mycoses
Endemic Mycoses
Opportunistic Mycoses
Mycotoxins
Antifungal Chemotherapy
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 Introduction
Mycology: Study of Fungi
100,000 species, fewer than 500 are medically
important, less than 50 species cause more than
90%of the fungal infections to humans and animals.
Fungal infections are mycoses
Highest Incidence candidiasis and
dermatophytosis
Able to produce disease in hosts that are debilitated
or immunocompromised.
Mycoses may be classified as superficial, cutaneous,
subcutaneous, or systemic, invading the internal
organs
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Pathogenesis of the Fungi
Portal of entry
primary mycoses respiratory portal;
inhaled spores
subcutaneous - inoculated skin; trauma
cutaneous and superficial
contamination of skin surface
Virulence factors thermal
dimorphism, toxin production,
capsules and adhesion factors,
hydrolytic enzymes, inflammatory
stimulants

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 Most mycoses are difficult to treat. Because
fungi are eukaryotes, they share numerous
homologous genes, gene products, and
pathways with their human hosts.

Antibiotics (penicillin) and immunosuppressive

drugs (cyclosporine).

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Immunology of the Mycoses

Antibody mediated immunity (B-cell, humoral)

Antibodies are often produced in response to a
fungal infection, but do not confer immunity.
Serological tests for identification of fungal
diseases detect these antibodies.

Cellular mediated immunity (T-cell)

T-cell immunity is effective in resistance to fungal
infections.

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What are fungi?

Eukaryotic, spore-bearing, heterotrophic

organisms that produce extracellular
enzymes and absorb their nutrition.

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Mycelium

Vegetative Hyphae - absorbs nutrients

Aerial Growing or existing in air

Reproductive (Fertile) Hyphae

aerial hyphae above media
Reproductive spores

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Vegetative Structures

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GENERAL PROPERTIES AND CLASSIFICATION OF
FUNGI

Classified as Yeasts and Molds

Yeast Unicellular
Molds multicellular filaments (hyphae)
forming fungi body (mycelium)
- Hyphae, septated or nonseptated
These dimorphic pathogens usually
change from a multicellular hyphal form
in the natural environment to a budding,
single-celled form in tissue.

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Yeast

Round, oval or elongated unicellular

cells.
Few capsulated
Reproduction
Sexual
Asexual : by budding (blastoconidia or
blastospores)
May give arise to pseudohyphae
Candida albicans
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Molds

Multicellular
Form branching filamentous called hyphae
Hyphae form mycelium
Hyphae may be septate of aseptate
Reproduction:
Asexual: by Conidia and spore
Sexual.

Dermatophytes
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Dimorphic fungi:

Dimorphism this term is used to describe a

fungus which occurs in two different forms
(temperature and place), for example, some
pathogenic fungi are filamentous in culture
and yeast-like in infected tissues.
37C yeast
20 30 C molds.
Examples:
Paracoccidioides brasiliensis

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 Fungal Morphology
Hypae (threads) Yeasts
making up a mycelium

Many pathogenic fungi are

dimorphic, forming
hyphae at ambient
temperatures but yeasts at
body temperature.

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 When a mold is isolated from a clinical
specimen, its growth rate, macroscopic
appearance, and microscopic
morphology

The most helpful phenotypic features are

morphology of the asexual reproductive
spores, or conidia.

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Reproduction
- Asexual reproduction
- Budding, fission
- Asexual spore - mitosis
- zoospores, sporangiospores.
- oospores, zygospores, chlamydospores

Sexual reproduction
sexual spore - meiosis
ascospore, basidiospore

Some fungi have no sexual reproduction

(Imperfect fungi).
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Medically Important Fungi

Deuteromycota- no sexual spores

Zygomycota- coenocytic fungi
Ascomycota-
septate
dust like spore
Basidomycota
septate
fleshy base; mushrooms

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GROWTH AND ISOLATION OF FUNGI

Sabourauds agar

Other media, such as inhibitory mold agar,

have facilitated the recovery of fungi from
clinical specimens. To culture medical fungi
from non-sterile specimens, antibacterial
antibiotics (eg, gentamicin,
chloramphenicol) and cycloheximide are
added to the media to inhibit bacteria and
saprobic molds, respectively.

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 Topographic Grouping of Fungi:
(most often used)
Superficial -
- Confined to the outermost layers of the skin
and hair.

- No host cellular or inflammatory response due

to organisms being remote from living tissue.

- Essentially no pathology; the disease is

recognized purely on cosmetic basis.

- Factors that can cause the fungus to become

more visible include high humidity, as well as
immune or hormone abnormalities.
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 Cutaneous
- In the keratin of the skin, nails, and hair.
- The disease is called a dermatophytosis or
dermatomycosis.
- Host immune responses may be evoked resulting
in pathologic changes expressed in the deeper
layers of the skin.
- The resulting diseases are often called ringworm
or tinea
- Cutaneous mycoses are caused by
Microsporum ,
Trichophyton,
Epidermophyton.
- One common disease is the athelets foot.
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 Subcutaneous mycoses

- Involve the dermis, subcutaneous tissues,

muscle and fascia.

- These infections are chronic and can be

initiated by piercing trauma to the skin
which allows the fungi to enter.

- These infections are difficult to treat and

may require surgical interventions such
as debridement.

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 Systemic

- Attack the deep tissues and organ

systems.

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 Categories of systemic disease:

Those caused by truly pathogenic fungi (primary)

with the ability to cause disease in the normal
human host when the inoculum is of sufficient size
(Histoplasma capsulatum, Blastomyces dermatitidis,
Coccidioides immitis, Paracoccidioides braziliensis).
In general primary pathogens that cause systemic
mycoses are dimorphic

Those caused by opportunistic fungi, low virulence

organisms, which require the patient's defenses to be
lowered before the infection is established
(Aspergillus spp. Candida albicans, Cryptococcus
neoformans).
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 SUPERFICIAL MYCOSES

1. Pityriasis Versicolor
- stratum corneum
- Malassezia furfur
The diagnosis is confirmed by
direct microscopic examination of
scrapings of infected skin, treated
with 1020% potassium hydroxide
(KOH) or stained with calcofluor
white. yeast and hyphae

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2. Piedra

- Black piedra is a nodular

infection of the hair shaft
caused by Piedraia
hortae.

- White piedra, due to

infection with
Trichosporon species.

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 Cutaneous Mycoses
- They are spread from infected persons by direct
contact.
- Microsporum is also spread from animals such as
dogs and cats.
- Tropism to specific tissue Tinea captitis, corporis,
barbae, cruris, pedis, unguium.
- Pruritic itchy

- Microsporum spp. - in hair, skin, rarely nails; frequently

in children, rarely in adults; often spontaneous
remission occurs (ringworm).
- Trichophyton spp. - hair, skin & nails; in both children
& adults (athletes foot).
- Epidermophyton spp. - skin, nails, rarely hair; in adults,
rarely in children (ringworm).
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Severe nail infection with Trichophyton rubrum in
a 37-year-old male AIDS patient.
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Dermatophitid
Dermatophytids are fungus-free disseminated
skin lesions resulting from induced sensitization
in patients with ringworm infections

These eruptions (dermatophytids, or identity or

id reactions) are allergic reactions to the
fungus.

The most common dermatophytid is an

inflammation in the hands resulting from a
fungus infection of the feet. Dermatophytids
normally disappear when the primary ringworm
infection is treated
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 SUBCUTANEOUS MYCOSES

The fungi that cause subcutaneous mycoses

normally reside in soil or on vegetation.

A superficial cut or abrasion may introduce an

environmental mold with the ability to infect the
exposed dermis.

Chronic, supperative or granulomatous infections

(hands, feet)

Can extend through the lymphatics or form sinus

tracts.
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SPOROTRICHOSIS

Sporothrix schenckii
Dimorphic
Sporotrichosis a chronic granulomatous
infection.
Spread with involvement of the draining
lymphatics and lymph nodes.

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Sporothrix schenckii
Sporotrichosis (rose-gardeners disease)
Very common saprobic fungus that
decomposes plant matter in soil
Infects appendages and lungs
Lymphocutaneous variety occurs when
contaminated plant matter penetrates
the skin and the pathogen forms a
nodule, then spreads to nearby lymph
nodes.
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 CHROMOBLASTOMYCOSIS

Non-contagious skin diseases characterized

by the development of a warty lesion that has
a cauliflower appearance.

The infection is chronic and characterized by

the slow development of progressive
granulomatous lesions that in time induce
hyperplasia of the epidermal tissue.

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- Caused by dematiaceous fungi, having
melanized cell walls:

Fonsecaea pedrosoi,
Cladosporium spp.,
Phialophora spp.

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 MYCETOMA

Mycetoma is a chronic subcutaneous infection

induced by traumatic inoculation with any of several
saprophytic species of fungi or actinomycetous
bacteria that are normally found in soil.

The hallmark of a mycetoma is localized swelling and

the formation of fistulae that contain hard granules
composed of hyphae and inflammatory tissue (eg,
macrophages, fibrin).

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 Actinomycetoma is a mycetoma caused
by an actinomycete;

Eumycetoma (maduromycosis, Madura

foot) is a mycetoma caused by a fungus.

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 In tissue, the mycetoma granules may
range up to 2 mm in size. The color of the
granule may provide information about
the agent.

Madurella mycetomatis produces a dark

red to black granule. These granules are
hard and contain intertwined, septate
hyphae

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Systemic mycoses

Dissemination of any fungal agent or

yeast, to involve any tissue or organ.
Agent must be dimorphic.

Histoplasma capsulatum
Coccidioides immitis
Paracoccidioides brasiliensis
Blastomyces dermatitidis

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 Habitat: in nature in dry soil

These infections result from inhalation of the spores of

dimorphic fungi that have their mold forms in the soil.
Within the lungs, the spores differentiate into yeasts or
other specialized forms, such as spherules.

Most lung infections are asymptomatic and self-limited.

However, in some persons, disseminated disease to

organs death

Infected persons do not communicate these diseases to

others. (No person-to-person transmission. )

For the agents of endemic mycoses, virulence is

associated with -glucan in their cell walls.

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 Immunity

Virulence (-glucan in their cell walls)

This process typically leads to granulomatous

inflammation and the production of both
antibodies and cell mediated immunity.

The induction of Th1 cytokines (interleukin- 12,

interferon-, tumor necrosis factor ) will amplify
the cellular defenses, activating macrophages
and enhancing their fungicidal capacity.
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COCCIDIOIDOMYCOSIS
- C. immitis

C. immitis is a
dimorphic fungus
that exists as a mold
in soil and as a
spherule in tissue

Arthrospores are light and carried by the wind

The can be inhaled and infect the lungs 60
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Pathogenesis

Lungs (arthrospores form spherules)

Ruptured
Disseminate into bones and CNS
(meningitis)
Delayed hypersensitivity
(granuloma) with positive skin test
(Coccidioidin, Spherulin)

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 Diagnosis

Specimen
- Sputum
- Spinal fluid
- Blood
- Urine
- Tissue biopsies
Microscopy: Materials should be examined
fresh for typical spherules. (KOH or Calcofluor)
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 Culture
- Sabourauds agar at 37C
- Because the arthroconidia are highly
infectious, suspicious cultures are examined
only in a biosafety cabinet

Serology
- Within 24 weeks after infection, IgM
antibodies to coccidioidin can be
detected with a latex agglutination test.

- Specific IgG antibodies are detected by the

immunodiffusion (ID) or complement
fixation (CF) test.
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 Histoplasma
Histoplasma capsulatum is a dimorphic soil
saprophyte that causes histoplasmosis, the most
prevalent pulmonary fungal infection in humans
and animals.

Two types of asexual spores:

- Tuberculate macroconidia
- Microconidia if inhlaed causes infection

In tissue or in vitro on rich medium at 37C, the

hyphae and conidia convert to small, oval yeast
cells . 67
 Nonencapsulated despite its name.
Present in bird and bat droppings, so
outbreaks of pneumonia occur when
cleaning chicken coops or spelunking
(cave exploring).

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Two types of asexual spores:
-Tuberculate macroconidia
-Microconidia if inhlaed causes infection

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Pathogenesis
Inhaled spores engulfed by macrophages and
develop into yeast.

In tissue, in tissue it occurs as an oval budding yeast

inside macrophages.

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Disseminated Histoplasma capsulatum, skin infection.
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BLASTOMYCOSIS
Blastomyces dermatitidis causes
blastomycosis

Fungi are isolated from soil and rotten

wood. The rarest systemic fungal infection.

Inhalation of the conidia causes human

infection.

The yeast is round with a doubly refractive

wall and a single broad-based bud (Large
yeast cells with single bud).
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Paracoccidioides

Paracoccidioides braziliensis

Dimorphic fungus that exists as a mold in

soil and as a yeast in tissue.

The yeast is thick-walled with multiple

buds

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Large yeast cells with multiple buds (mariners wheel).

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The 4 fungi have 3 clinical presentations:

1) Asymptomatic: The majority of cases are

asymptomatic or mild respiratory illnesses
that go unreported.

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 2) Pneumonia:
- A mild pneumonia can develop with fever,
cough, and chest X-ray infiltrates.
- Granulomas with calcifications can follow
resolution of the pneumonia.
- A small percentage of persons will develop a
severe pneumonia (chronic cavitary
pneumonia, marked by weight loss, night
sweats, and low-grade fevers, much like a
chronic tuberculosis pneumonia).
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 3) Disseminated:
Rarely, (meningitis, bone lytic
granulomas, skin granulomas that break
down into ulcers, and other organ
lesions).

- This disseminated form commonly occurs

in the immunocompromised host

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Diagnosis

All 4 are best diagnosed by obtaining a biopsy

of the affected tissue: bronchoscopic biopsy of
lung lesions, skin biopsy , etc

The tissue can be examined with silver stain for

yeast or can be grown on Sabouraud's agar or
blood agar.

Skin tests are not very helpful for diagnosis, as

many people have been previously exposed
asymptomatically and will have a positive test
anyway. Serologic tests can be helpful
(complement fixation, latex agglutination).

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Treatment

Acute pulmonary histoplasmosis and

coccidioidomycosis usually require no treatment,
as the infection is mild.

For chronic or disseminated disease, itraconazole

or amphotericin B is often required for months!

All Blastomyces infections require aggressive

amphotericin B or itraconazole treatment.

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OPPORTUNISTIC MYCOSES

Opportunistic fungi fail to induce disease

in most immunocompetent persons but
can do so in those with impaired host
defenses

- Candida, Cryptococcus, Aspergillus,

Mucor, and Rhizopus.

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 Most are inhibited by cycloheximide.

Grouped by type of mycelia produced.

Septate vs. aseptate
Hyaline vs. dematiaceous

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CANDIDA
Candida albicans,

causes thrush, vaginitis, esophagitis, diaper

rash, and chronic mucocutaneous candidiasis.

It also causes disseminated infections

endocarditis (especially in intravenous drug
users), bloodstream infections (candidemia),
and endophthalmitis.

Infections related to indwelling intravenous and

urinary catheters are also important. 89
Properties

- C. albicans is an oval yeast with a single

bud
- It is part of the normal flora of mucous
membranes of the upper respiratory,
gastrointestinal, and female genital
tracts.
- In tissues it may appear as yeasts or as
pseudohyphae
- True hyphae are also formed when C.
albicans invades tissues.
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Transmission

As a member of the normal flora, C.

albicans is already present on the skin
and mucous membranes.

Predisposes to skin infections when using

as needles (intravenous drug use) and
indwelling catheters.

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Pathogenesis & Clinical Findings

C. albicans in the mouth produces white

patches called thrush

Vaginitis with itching and discharge is

favored by high pH, diabetes, or use of
antibiotics.

Diaper rash in infants occurs when wet

diapers are not changed promptly

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 In immunosuppressed individuals, Candida
may disseminate to many organs or cause
chronic mucocutaneous candidiasis (CMC).

Candida esophagitis, often accompanied by

involvement of the stomach and small
intestine, is seen in patients with leukemia and
lymphoma.

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Chronic mucocutaneous
candidiasis
Chronic mucocutaneous
candidiasis (CMC) is the label
given to a group of overlapping
syndromes that have in common
a clinical pattern of persistent,
severe, and diffuse cutaneous
candidal infections. These
infections affect the skin, nails and
mucous membranes.

Defects related to cell-

mediated immunity.

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Mucutaneous candidiasis: response to
fluconazole

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Opportunistic Infection by Candida
albicans in an AIDS Patient

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Laboratory Diagnosis

In exudates or tissues, budding yeasts and

pseudohyphae appear gram-positive and
can be visualized by using calcofluor-white
staining.

In culture, typical yeast colonies are

formed that resemble large staphylococcal
colonies.

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 Germ tubes form in serum at 37C, which
serves to distinguish C. albicans from
most other Candida species

Chlamydospores are typically formed by

C. albicans but not by other species of
Candida on cornmeal agar.

Serologic testing is rarely helpful

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CRYPTOCOCCUS

Cryptococcus neoformans causes

cryptococcosis, especially cryptococcal
meningitis.

Cryptococcosis is the most common, life-

threatening invasive fungal disease
worldwide. It is especially important in
AIDS patients.

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Properties
C. neoformans is an oval, budding yeast
surrounded by a wide polysaccharide
capsule
It is not dimorphic.
This organism forms a narrow-based bud

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Transmission

C. neoformans occurs widely in nature and

grows abundantly in soil containing bird
(especially pigeon) droppings.

The birds are not infected. Human infection

results from inhalation of the organism.

There is no human-to-human transmission.

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 Pathogenesis & Clinical Findings
Lung infection is often asymptomatic or may
produce pneumonia.

Disease caused by C. neoformans occurs

mainly in patients with reduced cell-mediated
immunity, especially AIDS patients, in whom
the organism disseminates to the central
nervous system (meningitis) and other organs.

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 In some patients with AIDS who are
infected with Cryptococcus, treating the
patient with highly active antiretroviral
therapy (HAART) causes an exacerbation
of symptoms.

HAART increases the number of CD4 cells,

which increases the inflammatory
response.

Immune reconstitution inflammatory

syndrome (IRIS). 110
Laboratory Diagnosis

In spinal fluid mixed with India ink, the yeast

cell is seen microscopically surrounded by
a wide, unstained capsule.

The organism can be cultured from spinal

fluid and other specimens. The colonies
are highly mucoid.

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 Serologic tests can be done for both
antibody and antigen. In infected spinal
fluid, capsular antigen occurs in high titer
and can be detected by the latex
particle agglutination test.

This test is called the cryptococcal

antigen test, often abbreviated as
crag.

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ASPERGILLUS

Aspergillus fumigatus, cause infections of

the skin, eyes, ears, and other organs;
fungus ball in the lungs; and allergic
bronchopulmonary aspergillosis.

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Properties

Aspergillus species exist only as molds;

they are not dimorphic.

They have septate hyphae that form V-

shaped (dichotomous) branches

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Transmission

These molds are widely distributed in

nature.

They grow on decaying vegetation,

producing chains of conidia.

Transmission is by airborne conidia.

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Pathogenesis & Clinical Findings

A. fumigatus can colonize and later invade

abraded skin, wounds, burns, the cornea, the
external ear, or paranasal sinuses. It is the most
common cause of fungal sinusitis.

Aspergilli are well-known for their ability to grow

in cavities within the lungs, especially cavities
caused by tuberculosis. (fungal balls)

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 Allergic bronchopulmonary aspergillosis
(ABPA) is a hypersensitivity reaction to the
presence of Aspergillus in the bronchi.

Patients with ABPA have asthmatic

symptoms and a high IgE titer against
Aspergillus antigens, and they expectorate
brownish bronchial plugs containing
hyphae.

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 Laboratory Diagnosis

Biopsy specimens show septate, branching

hyphae invading tissue

Cultures show colonies with characteristic

radiating chains of conidia

In persons with invasive aspergillosis, there

may be high titers of galactomannan antigen
in serum

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 MUCOR & RHIZOPUS
Mucormycosis is a disease caused by
saprophytic molds (e.g., Mucor, Rhizopus)

Found widely in the environment.

They are not dimorphic.

These organisms are transmitted by airborne

asexual spores and invade tissues of patients with
reduced host defenses.

They proliferate in the walls of blood vessels,

particularly of the paranasal sinuses, lungs, or gut,
and cause infarction and necrosis of tissue distal
to the blocked vessel. 121
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 Patients with diabetic ketoacidosis,
burns, bone marrow transplants, or
leukemia are particularly susceptible.

Rhinocerebral mucormycosis, in which

mold spores in the sinuses germinate to
form hyphae that invade blood vessels
that supply the brain

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Control of Mycotic Infections
Immunization is not usually effective.
Control involves intravenous
amphotericin B, flucytosine, azoles and
nystatin.
In some cases surgical removal of
damaged tissues
Prevention limited to masks and
protective clothing to reduce contact
with spores

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 Mycotoxins
Many fungi produce poisonous substances
called mycotoxins that can cause acute or
chronic intoxication and damage.

The mycotoxins are secondary metabolites,

and their effects are not dependent on
fungal infection or viability.

135
 Mushrooms their ingestion results in a
dose-related disease called mycetismus.
(mushroom poisoning).
Cooking has little effect on the potency
of these toxins, which may cause severe
or fatal damage to the liver and kidney.

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 One of the most potent is aflatoxin,
which is elaborated by Aspergillus flavus
and related molds and is a frequent
contaminant of peanuts, corn, grains,
and other foods.

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Antifungal drugs

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 SITES OF ACTION OF COMMON ANTIFUNGAL DRUGS
BIND TO ERGOSTEROL
POLYENES
AND FORM PORES
(CHANNELS)

GLUCAN
SYNTHASE
INHIBITORS

IMIDAZOLES
TRIAZOLE

ALLYLAMINES

OTHER

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PRIMARY ANTI-FUNGAL AGENTS

1. Polyene derivatives
Amphotericin B
Nystatin
2. Azoles
Ketoconazole
Fluconazole
Itraconazole
Voriconazole

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MECHANISMS OF ACTION

Polyenes Ergosterol in cell

membrane
Azoles Interfere with
ergosterol synthesis
Griseofulvin Forms a barrier to
fungal growth

5 - FC
Inhibits RNA synthesis

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Mechanism of resistance

Resistance:
Replacement of ergosterol by other sterols
in fungal plasma membrane.

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